HospitalInspections.org

Based on review of Columbus Specialty Hospital's Emergency Preparedness Plan and interviews with staff it was determined that the facilities plan was not in substantial compliance set forth in Appendix Z.
This could place all residents at risk in the event of an emergency.
The findings include:
During a review of the facilities Emergency Preparedness Plan and staff interview on 09/23/2019 documentation was not available to show the facility had participated in a full scale exercise nor a second full scale exercise or table top exercise.
These findings were confirmed by Staff Vice President, Human Resources and Staff CEO/CFO at the time of discovery.
Reference CMS S&C Letter QSO19-06-ALL dated February 1, 2019, S&C Letter 17-29-ALL dated June 2, 2017. Appendix Z Rev. 186, Issued 03-04-19 section E 0039.

Based on record review and staff interview it was determined the facility failed to maintain smoke detectors.
This could place all patients at risk in the event of fire.
The findings include:
During a record review of the facility with Staff M on 09/23/2019 between 12:30 PM and 3:30 PM observation revealed the following:
A report is not available for sensitivity testing being conducted on smoke detectors.
These findings were confirmed by Staff M at the time of discovery.
Reference 2012 NFPA 101 Chapter 19 section 19.3.4.1, Chapter 9 section 9.6.1.3 Chapter 4 section 4.6.12.1; 2010 NFPA 72 Chapter 14 section 14.4.5.3

Based on observation and staff interview it was determined the facility failed to maintain smoke barriers to have a minimum ½ hour fire resistance.
This could place patients in 2 of 4 smoke compartments at risk in the event of fire.
The findings include:
During a tour of the facility with Staff M on 09/23/2019 between 12:30 PM and 3:30 PM observation revealed the following:
There are 2 conduits penetrating the smoke barrier wall above the ceiling at the cross corridor doors on the room 4416 side that are not fire stopped.
These findings were confirmed by Staff M at the time of discovery.
Reference 2012 NFPA 101 Chapter 19 section 19.3.7.1, 19.3.7.3, Chapter 8 section 8.5.7.4, 8.3.5, 8.3.5.1, Chapter 4 section 4.6.12.1

Based on record review and staff interview it was determined the facility failed to conduct fire drills at expected and unexpected times under varying conditions at least quarterly on each shift.
This could place all patients at risk in the event of fire.
The findings include:
During a record review of the facility with Staff M on 09/23/2019 between 12:30 PM and 3:30 PM observation revealed the following:
A report is not available where fire drills have been conducted.
These findings were confirmed by Staff M at the time of discovery.
Reference 2012 NFPA 101 Chapter 19 section 19.7.1.6, Chapter 4 section 4.7.6

Based on record review and staff interview it was determined the facility failed to exercise the generator by running 30 minutes 12 times per year in 20-40 day intervals.
This could place all patients at risk in the event of electrical power failure.
The findings include:
During a record review of the facility with Staff M on 09/23/2019 between 12:30 PM and 3:30 PM observation revealed the following:
A report is not available where the generator is run 30 minutes per month under load 12 times per year.
These findings were confirmed by Staff M at the time of discovery.
Reference 2012 NFPA 99 Chapter 6 section 6.4.4.1.1.3; 2010 NFPA 110 Chapter 8 section 8.4.1, 8.4.2; 2012 NFPA 101 Chapter 4 section 4.6.12.1